Citation Nr: 0614043
Decision Date: 05/12/06 Archive Date: 05/25/06
DOCKET NO. 03-08 449A ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Cleveland,
Ohio
THE ISSUE
Entitlement to service connection for an acquired psychiatric
disorder, including post-traumatic stress disorder (PTSD).
REPRESENTATION
Appellant represented by: Veterans of Foreign Wars of
the United States
ATTORNEY FOR THE BOARD
J. Johnston, Counsel
INTRODUCTION
The veteran had active military duty from May 1974 to May
1976.
This matter comes before the Board of Veterans' Appeals
Board) on appeal from a November 2002 rating decision issued
by the Department of Veterans Affairs (VA) Regional Office
(RO) in Cleveland, Ohio, which denied service connection for
PTSD. During the pendency of this appeal, the veteran
requested a hearing before a Veterans Law Judge (VLJ). He
missed the initially scheduled hearing, successfully moved to
be provided a subsequent hearing, and failed to report for
the subsequent hearing. There is no additional hearing
request on file. The case is now ready for appellate review.
FINDINGS OF FACT
1. All relevant evidence necessary for a fair and equitable
disposition of the appeal has been requested or obtained.
2. There is no competent clinical diagnosis that the veteran
has PTSD.
3. The veteran has received multiple other psychiatric
diagnoses including bipolar disorder, paranoid schizophrenia,
psychosis not otherwise specified, and depressive disorder
not otherwise specified, and all of these diagnoses were
first made decades after the veteran was separated from
service, and there is a complete absence of any competent
medical opinion relating any of these diagnoses to any
incident, injury or disease of active military service.
CONCLUSION OF LAW
An acquired psychiatric disorder, including PTSD, was not
incurred or aggravated in active military service.
38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5102, 5103,
5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307,
3.309 (2005).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Laws and Regulations: VCAA and regulations implementing this
liberalizing legislation are applicable to the veteran's
claim. VCAA requires VA to notify claimants of the evidence
necessary to substantiate their claims, and to make
reasonable efforts to assist claimants in obtaining such
evidence.
The veteran was provided formal VCAA notice in March 2002,
prior to the issuance of the initial adverse rating decision
now on appeal from November 2002. This notification informed
the veteran of the evidence necessary to substantiate his
claim, the evidence he was responsible to submit, the
evidence VA would collect on his behalf, and advised he
submit any relevant evidence in his possession. The
following month in April 2002, the RO also notified the
veteran of the necessity for him to report stressors in
support of a valid diagnosis of PTSD. The veteran was
provided the regulatory implementation of VCAA, and the
regulations governing entitlement to the benefit he seeks in
statements of the case. All known available records of the
veteran's treatment both privately and with VA have been
collected for review, and the veteran was provided a VA
examination which is adequate for rating purposes.
The veteran does not argue nor does the evidence on file
suggest that there remains any outstanding relevant evidence
which has not been collected for review. Indeed, the Board
remanded this appeal in August 2004 specifically for the
purpose of ensuring that all available records were
collected. The National Personnel Records Center in
St. Louis, Missouri was contacted to ensure that all
available records had been collected. The veteran was
requested to provide a more specific statement of stressors.
The RO contacted Headquarters, United States Marine Corps,
for a unit history which was provided. The Board finds that
VCAA is satisfied in this appeal. 38 U.S.C.A. §§ 5102, 5103,
5103A, 5107; Quartuccio v. Principi, 16 Vet. App. 183 (2002).
To the extent that the veteran may not have been provided
VCAA notice with respect to downstream issues in accordance
with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006),
in the absence of competent evidence of a valid diagnosis of
PTSD, and in the absence of any evidence relating current
multiple psychiatric diagnoses other than PTSD to any
incident, injury or disease of active service, any failure to
provide such notice must be harmless error.
Service connection may be established for disability
resulting from disease or injury incurred or aggravated in
line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303.
Service connection may also be granted for certain specified
diseases, including psychoses, which are shown to have become
manifest to a compensable degree within one year from the
date of service separation. 38 U.S.C.A. §§ 1101, 1112, 1113,
1137; 38 C.F.R. §§ 3.303, 3.309. Service connection may also
be granted for any disease diagnosed after discharge, when
all of the evidence, including that pertinent to service,
establishes that the disease was incurred in service.
38 C.F.R. § 3.303(d).
For the showing of chronic disease in service, there is
required a combination of manifestations sufficient to
identify a disease entity, and sufficient observation to
establish chronicity at the time, as distinguished from
merely isolated findings. Continuity of symptomatology is
required where the condition noted during service is not
shown to be chronic, or when a diagnosis of chronicity may be
legitimately questioned. When chronicity in service is not
adequately supported, a showing of continuity after discharge
is required to support the claim. 38 C.F.R. § 3.303(b).
Service connection for PTSD requires medical evidence
diagnosing the condition in accordance with § 4.125(a) of
this chapter, a link established by medical evidence between
current symptoms and an inservice stressor, and credible
supporting evidence that the claimed inservice stressor
occurred. If a veteran establishes that he engaged in combat
with the enemy and the claimed stressor is related to that
combat, in the absence of clear and convincing evidence to
the contrary, and provided that the claimed stressor is
consistent with the circumstances, conditions, or hardships
of such service, the veteran's lay testimony alone may
establish the occurrence of the claimed in-service stressor.
Without established combat with the enemy, stressors claimed
by a veteran in support of a valid diagnosis of PTSD must be
independently corroborated by objective evidence. 38 C.F.R.
§ 3.304(f).
The 1945 Schedule for Rating Disabilities (Schedule)
incorporates by reference the American Psychiatric
Association's, Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition (DSM-IV). 38 C.F.R. Part 4.
Analysis: The service medical records contain no complaint,
finding, treatment or diagnosis for an acquired psychiatric
disorder of any type. In February 1975, a record entry notes
that the veteran reportedly had been told by a warrant
officer at his last command that he should see a
psychiatrist. The veteran reported that he felt at times he
could not control himself, he had headaches, and he wandered
off when he should be somewhere else. The report indicates
that the veteran was referred for evaluation or counseling,
but there is no indication that the veteran ever sought
further treatment or attended any subsequent counseling
session. The April 1976 physical examination for separation
from service notes that the veteran was psychiatrically
normal and contains no indication of any psychiatric
abnormality of any kind.
Following service separation, there is a complete absence of
any objective medical or other evidence which shows or
suggests that the veteran sought or required any form of
psychiatric care or treatment until 2001, some 25 years after
he was separated from service.
In September 2001, the veteran was hospitalized at the
private MetroHealth Medical Center. At intake, the veteran
specifically denied any prior psychiatric difficulty. He
reported that he had recently felt that the mafia were after
him because there were Cadillacs everywhere on his block, and
there was a parked van. He noticed that when he would leave
work that traffic would suddenly open up and give him a slot.
He felt that the people next door wanted his house. He also
reported that he frequently did not like to leave his home
because he was afraid that people might harm him. He
reported that the television sent him visual images. He
provided his personal history, including schooling, service
in the military, and steady employment following service
separation.
At intake, a medical doctor was first impressed that the
veteran might have had a mixed bipolar episode, although he
did not meet the diagnostic criteria for bipolar. He also
assessed possible schizophrenia, but noted that the veteran
did not completely meet the criteria for paranoid
schizophrenia either. It was thought that perhaps the
veteran met the criteria for a delusional disorder. By the
end of October 2001, the assessment was changed to a
PTSD-induced psychosis. At this time, records note that the
veteran had been having flashbacks since the World Trade
Center bombing, although the subject of these flashbacks was
not reported. The veteran reported a belief that the
Government was trying to get him, people were talking to him
through the TV, and that the phone in his home was bugged by
the Government. He believed that his wife was working for
the Government, that she started everything, and that she was
trying to get him into the hospital. This report also stated
that the veteran "had been having flashbacks of his days in
Vietnam," but not a single detail of any reported flashbacks
is contained in the lengthy examination report. The veteran
discussed suicidal ideation. He denied that he was hearing
voices, but stated that he had been getting messed up from
the TV, and felt that people were putting thoughts into his
head. He felt like his thoughts were being broadcasted on TV
and radio. It was noted that the veteran had a "history of
PTSD" diagnosed some time ago, but there is no specific
reference as to where such diagnosis may have been made, or
by whom.
On mental status examination, there was some evidence of
paranoid delusions with thought insertion and thought
broadcasting. Although a PTSD-induced psychosis was noted at
this time, the report of examination containing this Axis I
diagnosis contains no discussion whatsoever of any particular
incident or incidents which occurred during the veteran's
military service, other than then single comment that the
veteran reported having flashbacks of his days in Vietnam.
There was an essential absence of all or most of the DSM-IV
criteria for PTSD discussed or described in this hospital
report.
Several months after discharge from this private
hospitalization, the veteran was hospitalized at the
Cleveland VAMC in February 2002. Upon admission, he was
noted to have a history of PTSD, but was being admitted for
increasing paranoia. The veteran reported that for one and
one half years, the Government had been watching his home.
He felt the Government was trying to control him through both
the TV and the radio. He also believed that his wife was
involved in a conspiracy against him. He said that he had
been increasingly thinking about his time in Vietnam when he
was there for the evacuation. He believes the Government
spying on him is somehow connected to Vietnam. At admission,
the veteran reported not being compliant with his medications
for the previous four to five days. The only previous
psychiatric history was his earlier admission to MetroHealth.
The veteran admitted to talking to himself loudly but denied
hearing voices. The veteran's wife, however, reported that
the veteran talked loudly to himself as if he was conversing
with individual who was not there. It seemed like most of
these symptoms got worse after the 911 when he was glued to
the television set watching the news. The veteran denied any
psychiatric history prior to one and one half years ago. In
particular there were no psychotic or effective symptoms. It
was noted that the veteran had "a vague diagnosis of PTSD but
his clinical HX [history] is devoid of any SXS [symptoms]
suggestive of this disorder (no sig. trauma during the
service, no SXS whatsoever for 20 years after DC [discharge]
from the service)." These records again note that the
veteran had been married for many years with two grown
children and had worked all his life and was currently
employed.
During this hospitalization, the veteran was provided
psychological testing (MMPI) and it was noted that the most
frequent diagnosis for someone who scored as the veteran did
was paranoid schizophrenia, but testing was also indicative
for major depression and accompanying paranoid delusional
features, or a delusional disorder with the depression being
secondary. The veteran was noted to have delusions of
persecution, reference, and probably jealousy as well, and he
did harbor notions that his mind was being controlled. The
final assessment from this hospitalization for Axis I was
that the veteran had a psychosis not otherwise specified and
rule out late onset paranoid schizophrenia. There was no
diagnosis or assessment of PTSD.
The veteran was provided a VA psychiatric examination in
December 2005. The claims folder was made available for
review by the examining physician. Psychometric testing was
also performed. MMPI-2 testing was interpreted as showing
that the veteran endorsed symptoms typical of a depressive
disorder with psychotic features, suspiciousness, alienation,
inability to direct his experience, anxiety, and physical
complaints. It was noted that there was no indication of any
mental health problems treated while the veteran was in the
military. The earliest records of treatment were from
MetroHealth in 2001. He had been having paranoid delusions
and was being treated with antipsychotic medication. The
examining physician noted mention in both sets of records of
the veteran having a vague history of PTSD due to some
intrusive memories of his military service, but there was no
documented full assessment of PTSD symptoms that met the
criteria for a valid diagnosis of PTSD. He had continued to
be seen at the VA and was treated for psychosis and anxiety
problems, but the anxiety appeared primarily related to
chronic worry about financial and other problems precipitated
from the psychosis.
On examination, the physician took the veteran's history that
he had been stationed aboard ship off of Vietnam and that he
had participated in the evacuation of refugees on a merchant
marine ship. He did policing, disarming, and handing out
supplies. Some of the refugees had weapons and jumped ship
to avoid surrendering them. He reported on one occasion
having a weapon pointed at him, although this weapon was
confiscated and no shots were fired. He noted on one
occasion that an individual threw something aboard his ship
which was initially thought to be a hand grenade, but which
turned out to be a can. He had had a post-service hunting
accident in which he was struck in the head by three shotgun
pellets, but no other major accidents, injuries or trauma.
The VA physician did a detailed assessment of PTSD, and did
not find that the veteran met the criteria for a valid
diagnosis of PTSD. The veteran frequently felt anxious and
worried about finances and everyday events, but he did not
experience intense anxiety attacks, difficulty breathing,
sweating, or feeling of being constantly vigilant. At the
time of his hospitalizations, he was having auditory
hallucinations, delusions, and paranoid ideas of reference.
Most of these symptoms had cleared with consistent medical
treatment, however he still felt very suspicious and that
people did not have his best interest at heart.
Under diagnosis, the physician stated that the veteran did
not meet the DSM-IV criteria for PTSD. Instead, he had
atypical depressive and psychotic symptoms. For Axis I, the
physician diagnosed psychotic disorder not otherwise
specified and depressive disorder not otherwise specified.
Under current stressors, the physician documented
unemployment and psychosis. In response to questions posed,
the physician wrote that it was questionable whether the
events the veteran reported during military service met the
" A Criteria" for a diagnosis for PTSD. He did not have
enough other symptoms of PTSD to meet the criteria for a
valid PTSD diagnosis. His anxiety symptoms were more likely
due to psychosis and the related social, vocational and
mental functioning problems. This doctor also stated that no
current psychiatric symptomatology was likely related to the
veteran's military service.
A clear preponderance of the evidence on file is against the
veteran's claim for service connection for an acquired
psychiatric disorder. Although there are some vague
references to a history of PTSD in the clinical records on
file, only a single medical assessment record on file
actually contains an Axis I diagnosis of PTSD induced
psychosis, and that record fails to contain any documentation
of DSM-IV symptomatology consistent with such diagnosis
except for a single reference to the veteran having
flashbacks of his days in Vietnam. The balance of the report
that includes an Axis I PTSD diagnosis is instead entirely
consistent with the remainder of the evidence on file, which
clearly documents the veteran having a psychosis with
suspiciousness regarding the Government, his wife and
neighbors. The balance of the clinical evidence on file
clearly does not support a valid diagnosis of PTSD, but
instead includes a multiplicity of diagnoses, mostly of
either psychosis not otherwise specified, delusional
disorder, paranoid schizophrenia, and depression.
The December 2005 VA examination included a review of the
entire clinical record, and included diagnostic testing and
the VA psychiatrist conducting this examination concluded
that the veteran did not have a valid diagnosis of PTSD, but
instead had a psychotic disorder and depressive disorder, not
otherwise specified. A clear preponderance of the evidence
of record is against a finding that the veteran has a valid
diagnosis of PTSD, related to incidents of military service
or otherwise.
In the absence of a valid diagnosis of PTSD consistent with
the criteria therefor in the DSM-IV, it is unnecessary for
the Board to address specific stressors by the veteran
reported by him in support of his claim for service
connection for PTSD. That is, even if every stressful
incident reported by the veteran were taken as true and
corroborated, in the absence of a valid diagnosis of PTSD,
service connection for such disorder would not be warranted
in any event. Suffice it to say that the veteran is not
shown to have served in combat with the enemy, and did not
receive any documented awards which are recognized as
reflective of service in combat with the enemy.
Additionally, the Board finds that a clear preponderance of
the evidence on file is against a finding that any of the
veteran's multiple other valid psychiatric diagnoses are in
any way causally related to any incident, injury, or disease
of active military service. The veteran had no psychiatric
treatment during service, and the single record entry where
the veteran reportedly told medical personnel that he had
himself been told by a warrant officer to see a psychiatrist
is certainly not evidence of psychiatric disability during
service. The veteran never followed up on the offer of
psychological counseling, and the physical examination for
service separation noted he was psychiatrically normal.
There is a complete absence of any evidence which shows that
the veteran manifested a psychosis to a compensable degree
within one year after service separation. The veteran is
clearly shown to have had no post-service psychiatric history
or symptoms of any kind from service separation in 1976,
until he was first hospitalized at MetroHealth in 2001, a
period of some 25 years. All records on file show that
during that 25-year period, the veteran maintained a marriage
and family, with close family ties both immediate and remote,
and that he maintained steady gainful employment all during
this period.
The first findings of psychosis, psychotic disorder,
depressive disorder, possible bipolar disorder, and paranoid
schizophrenia, all occurred many years after service
separation, and there is no competent clinical opinion which
relates any of these diagnoses as causally related to any
incident, injury or disease of active military service.
Indeed, the December 2005 VA examination specifically found
it unlikely that the veteran's recent onset of psychotic
symptoms was in any way related to his period of military
service.
An award of service connection for an acquired psychiatric
disorder is not warranted. The veteran is not shown to have
a valid diagnosis of PTSD, related to service or otherwise.
Other diagnoses are first demonstrated 25 years after service
separation, and to be entirely unrelated to any incident of
service.
ORDER
Entitlement to service connection for an acquired psychiatric
disorder, including PTSD, is denied.
____________________________________________
F. JUDGE FLOWERS
Veterans Law Judge, Board of Veterans' Appeals
Department of Veterans Affairs